Statistical Association Criteria in Forensic Psychiatry A criminological evaluation of casuistry

Purpose. Identification of potential shared primary psychoprophylaxis and crime prevention is measured by analyzing the rate of commitments for patients–subjects to forensic examination. 
 
Material and method. The statistic trial is a retrospective, document–based study. The statistical lot consists of 770 initial examination reports performed and completed during the whole year 2007, primarily analyzed in order to summarize the data within the National Institute of Forensic Medicine, Bucharest, Romania (INML), with one of the group variables being ‘particularities of the psychiatric patient history’, containing the items ‘forensic onset’, ‘commitments within the last year prior to the examination’ and ‘absence of commitments within the last year prior to the examination’. The method used was the Kendall bivariate correlation. For this study, the authors separately analyze only the two items regarding commitments by other correlation alternatives and by modern, elaborate statistical analyses, i.e. recording of the standard case study variables, Kendall bivariate correlation, cross tabulation, factor analysis and hierarchical cluster analysis. 
 
Results. The results are varied, from theoretically presumed clinical nosography (such as schizophrenia or manic depression), to non–presumed (conduct disorders) or unexpected behavioral acts, and therefore difficult to interpret. 
 
Conclusions. One took into consideration the features of the batch as well as the results of the previous standard correlation of the whole statistical lot. The authors emphasize the role of medical security measures that are actually applied in the therapeutic management in general and in risk and second offence management in particular, as well as the role of forensic psychiatric examinations in the detection of certain aspects related to the monitoring of mental patients.


Ref
The forensic issues related to crime and psychiatric pathology generate controversies but also lead to discussions about the shortage of inter-departmental cooperation as well as difficulties to initiate and support prevention and psychoprophylaxis programs. Similarly, both detection and monitoring/follow-up of mental patients are difficult to evaluate, because one cannot ignore the will of the patient who usually refuses any psychiatric help and assistance. Thus, it becomes extremely difficult to address the antisocial potential of mental patients and of patients without mental disorders, implying considerable logistic and conceptual efforts [1,2]. The legal provisions regarding compulsory treatment continue to be the only means by which we can ensure proper therapeutic management in a limited group of patients with antisocial potential [3,4].

Objectives
This study proposes to emphasize the role that forensic medicine has, through forensic psychiatric examinations, in the detection of phenomena and identification of risk factors of criminal behavior, especially the violent one, and to highlight the need for an actual enforcement of legal provisions regarding compulsory treatment [5,6].

Material and Method
A statistical case analysis was performed within "Mina Minovici" INML, focusing on primary forensic psychiatric examination, in order to detect the medical and social phenomena of legal cases. A group variable © 2011, Carol Davila University Foundation database was created, with each of the variables consisting of several items [7]. The statistical frequency recording contained the primary forensic psychiatric examination reports, which have been completed for a full year, between 1.01.2007 and 31. 12.2007.
 The above-mentioned database was used for this work, excluding the cases where the personal record data was not complete and the cases have been concluded as neurotic pathology.  The analyzed statistical lot contains a total of 749 cases.  This is a passive, retrospective descriptive analysis, not involving the examined person and using the data recorded in the forensic medical reports.  The correlations between variables in the INML database were analyzed by using the Kendall method.  Since the results have shown no correlations with the group variable "particularitiespsychiatric patient history", which also contains the item "commitments within the last year", meaning a psychiatric commitment within the calendar year prior to the examination, the variables have been re-coded in accordance with the medical history pattern and with the specificity of a forensic psychiatric examination. Nosological classifications have been regrouped into three models for similar reasons. Another correlation was performed by using the Kendall method, which found that the new variable regarding psychiatric commitments within the year prior to the examination correlates with the following new group variables, i.e. the variable "minors" (examined persons aged 14 to 17), the variable "adults" (including the age group theoretically representing the active age, 18 to 64), the variable "65 and above", the variable "mental retardation" and the variable "cognitive loss", a mixed group defining the cognitive deficit, irrespective of gravity.  The new variable "commitments" refer to patient psychiatric commitments within the year prior to the examination: a) As a common rule, the first forensic psychiatric examination is performed immediately after the offence has been perpetrated or after the legal proceedings have been initiated; b) The existence of psychiatric commitments within the last year signifies a less favorable evolution or the need for a psychiatric reassessment; c) The absence of commitments within the previous year implies a favourable evolution or indifference to the treatment; d) The perpetration of an offence settled by the law by psychotic patients or patients with cognitive deficits and with behavior or personality disorders is usually related to their antisocial potential.  The percentages of variables with positive correlations have been calculated. Cross tabulation and calculation of the estimated risk (odd ratio) as well as hierarchical clustering have been performed. The SPSS v.10 program for Microsoft Windows has been used for the calculation.
Descriptive statistics are used to describe the main features of a collection of data in quantitative terms. Descriptive statistics are distinguished from inferential statistics (or inductive statistics), in that descriptive statistics aim to quantitatively summarize a data set, rather than being used to support inferential statements about the population that the data are thought to represent [7,8]. Even when a data analysis draws its main conclusions using inductive statistical analysis, descriptive statistics are generally presented along with more formal analyses, to give the audience an overall sense of the data being analyzed. The statistical methods, which deal with censored data, can be divided into a 2 x 2 grid: parametric vs. nonparametric, and univariate vs. multivariate. There are a number of bivariate methods, including two correlation tests and three linear regression analyses. Cox hazard model (correlation test), EM algorithm, and Buckley-James method (linear regressions) can treat several independent variables if the dependent variable contains only one kind of censoring (i.e., upper or lower limits). Generalized Kendall's tau (correlation test) and Schmitt's binned linear regression can treat mixed censoring (including censoring in the independent variable), but can only have one independent variable.
Maurice G. Kendall (1907Kendall ( -1983 We propose an evaluation method based on Kendall's τ, a metric of rank correlation. The method is inexpensive, and representation independent [9,10,11]. We will show that Kendall's τ reliably correlates with human behavioral ratings and reading times. The Kendall tau rank correlation coefficient (or simply the Kendall tau coefficient, Kendall's τ or tau test) is a non-parametric statistic used to measure the degree of correspondence between two rankings and to assess the significance of this correspondence. In other words, it measures the strength of association of the cross tabulations [12,13,14]. It was developed by Maurice Kendall in 1938.

Results and Discussions
1. Preliminary Statistical Data 1.1. Table I contains indicative preliminary basic statistical data. The apparent redundancy of certain variables is due to successive recoding, which is necessary for each type of analysis; only the most suggestive of all aspects of data dissemination have been included. Standard deviations were found to be subunitary. The analysis of the database created at "Mina Minovici" INML indicates significant reliability both for the diagnosis and for the accurate recording of actual data; 1.2. The criminal history was found to be absent in 81.4%, the percentage cannot be attributed only to the 30.8% increase in the criminal activity among minors; 1.3. This study stems from the following picture: at "Mina Minovici" INML, within the primary forensic psychiatric examination boards, roughly 800 reports are completed each year, as requested by the competent institutions, for patients usually from Bucharest; the male sex is prevalent in a 3/1 ratio, as for criminal cases, thefts followed by murder, in aggregate, acts indicative of aggressive/violent behavior, account for more than half of them; the most involved age groups are 25 -44 and 14 -17, which was also noticed in previous studies [9,10]; the absence of criminal history, criminal history without violence and criminal history of the same type are prevalent. The presented characteristics bring about new elements of primary prevention (81.4% without criminal history) and risk management particularities (only 28 cases with violent criminal history out of 290 violent acts committed). 1.4. From a psychiatric perspective, most of the noticed data is theoretically presumed also by reference to the most involved age groups and gender. For future in-depth studies, one observation, which has been reiterated within the INML, is to be noted, concerning the sub-diagnosis of alcohol intake-related pathology; we must specify however that only certain data may be recorded in the forensic psychiatric examination. Which should also be noted is the fact that for a psychiatric pathology (I and II diagnosis axes) found in 658 patients, only 326 have shown psychiatric history. Of the latter, only approximately one third (101) were committed the year prior to the examination. The observations presented have supported this study, even more, so, the forensic psychiatric examination (and forensic medicine, in general) helps detect various phenomena, which may be extrapolated at a social level, and, more specifically, from the point of view of their dynamics [11].
2.2. This study only analyzed the relationships with the first two variables ("minors" and "adults") for the following reasons: they represent the patients who are mostly involved in criminal cases, and, implicitly, they are the subjects of the legal provisions regarding compulsory treatments; as a rule, cognition is within normal limits [12,13].
2.3. The "target" variables of the study correlate in turn with other variables. The positive correlations of these two variables are given in tables II and III.  (table IV) have been performed. The odds ratio is a measure of effect size, describing the strength of association or nonindependence between two binary data values. It is used as a descriptive statistic, and plays an important role in logistic regression. Unlike other measures of association for paired binary data such as the relative risk, the odds ratio treats the two variables in the same way, being compared symmetrically, and can be estimated by using some types of non-random samples. Apart from target variables, "theft -conduct disorders", "other violent actsconduct disorders" have also been applied to noncorrelated cohorts for theoretical reasons. These variables have been chosen because minors mostly commit thefts and robberies.
2.4.2. Studying the "theft -conduct disorder" relationship, for N = 749 n -conduct disorders = 172, thefts were committed by 6 patients diagnosed to have non-socialized conduct disorder and by 98 patients diagnosed to have socialized conduct disorder (98 thefts by patients with conduct disorders). With regard to the reasons for forensic psychiatric examination (for N = 749 -year 2007 -95% confidence interval), the estimated theft risk appears to be sub-unitary, considerably higher for the socialized conduct disorder (0.912).
2.4.3. Studying the "other violent acts -conduct disorder" relationship, for N = 749 and n valid cases of socialized conduct disorders with acts committed violently (except for murder and attempted murder) = 43, the estimated risk is above unit, 1.114.
2.4.4. A cross tabulation has been attempted for the "commitments -conduct disorders" relationship, but, although in theory statistical and mathematical calculations can also be made for a batch of 231 cases with only 5 cases for the analyzed item, we considered that the results cannot be very rigorous. However, we noted the following data involving discussions regarding primary prevention and psychoprophylaxis: out of 231 minor patients, 172 were diagnosed as having conduct disorder.
Of these 231 minors, 59 already had a criminal history, and only 14 were recorded as having a psychiatric history.
Of these 14, only 10 had been committed in a children's psychiatric hospital, 5 of whom the year prior to the examination (2 for non-socialized conduct disorder).
The absence of referral to the psychiatric specialist network of minors with non-socialized conduct disorder indirectly implies great malfunctions in the patient's social support, the disease being perceptible and not related to the environment or the circle of family and friends. The data reflects a lack of ability in the preventive management.
2.4.5. Table IV shows that the estimated risk is virtually different in minors than in other age categories in terms of the criminal history of violent acts, i.e. this risk is present only in the other age categories, being subunitary for minors.
The explanation would seem logical, as minors did not have the time to commit acts that are more serious. However, if we take into account the previous observations concerning the criminal history that already exists in almost a fifth of the minors, and, given a superunitary estimated risk of violent behavior in the same age group, we can judge that it is just a matter of time until violent acts committed by minors emerge.
Thus, it is necessary that risk and second offence management should be considered separately for adults and teenagers, with such criteria being revised for the latter. Table V shows that the age group 18 -64 is at risk of examination for any offence as well as in civil cases; both genders and virtually the entire non-neurotic pathology on both diagnosis axes are involved. This issue shows the need for other discussions regarding the risk and second-offence management evaluation criteria.

"Adults" Variable
2.5.2. For the "adults" -"commitments" relationship no further calculations have been made, the correlation being negative (0.01 significance level); out of N = 326 valid cases for adults with commitments, 168 patients had not been committed within the last year, while 46 had.
A benefit of certain commitments is obvious for vulnerable adults by psychiatric pathology toward behavior punishable by the law. This is actually, strongly related to outpatient monitoring, which seems to be deficient.
2.5.3. We also note data that has not been statistically analyzed due to a lack of significant correlation. Of the 72 schizophrenia patients, 68 were adults; 20 were involved in criminal cases; 54 patients had not been committed within the last year.
According to the INML database, most of the schizophrenic patients had been examined in order to be placed under a ban by the medical confinement.

Hierarchical cluster analysis
Hierarchical cluster analysis was also performed. The theoretically related variables with primary and tertiary psychoprophylactic management illustrated indirectly by admitting the preceding calendar year of the psychiatric medical -legal expertise have defined a number of variables strongly correlated positively (bivariate Kendall correlation method), at a level of significance of 0,01. The same variable is risk factor (on estimate odd ratio). The results obtained allowed us to consider risk factors in triggering the need for psychiatric medical-legal expertise and legal risk management indicators. The factors used to hierarchically cluster analysis [12,13,14]. Variables strongly correlated with "admissions" were entered in this analysis and were not detailed in this study (age group 65 years and over, global cognitive deficits group). Cluster analysis data can be interpreted, taking into account the frequency as it follows: 1. According to the manner of association (the cluster schedule of cases on one variables) to obtain a picture of the person's risk of reaching the medical -legal situation with the following hierarchy of psychiatric probabilities (presented in a descending order): a) minors; b) known criminal history (whether or not violent, because the frequency is higher for non-violent history) and personality disorder; c) absence of psychotic disorders and hospitalizations in the last year, or the year an offence under the criminal law has been commited or an involvement in a civil case has been noted (expertises of that time are available); d) age groups 65 years and older, and "adult"; e) criminal cases of murder and mental retardation; f) cognitive deficits, lack of criminal history and psychiatric history (usually show civil cases); 2. After gathering the variables, we obtained a slightly different hierarchy: